The-First-In-Man Randomized Trial of a ß3- adrenoceptor Agonist in Chronic Heart Failure BEAT-HF Henning Bundgaard, Anna Axelsson, Jakob H Thomsen, Mathias Sørgaard, Klaus Kofoed, Nana Køber, Rasmus B Hasselbalch, Henry Krum, Søren Boesgaard, Finn Gustafsson, Lars Køber, Kasper Iversen, Helge Rasmussen

Raised levels of intracellular sodium (Na i ) in the cardiomyocytes contribute to contraction abnormalities in heart failure (HF) The Na-K pump in the cardiomyocytes mediates Na i export – and evidence-based HF treatments stimulate the Na-K pump (ß blockers, ACE inhibitors, aldosterone antagonists) ß3 adrenoceptor (AR) agonists stimulate the Na-K pump through the NO/cGMP/PKG pathway – mediating Na i export (Bundgaard et al, Circulation 2010) Background – chronic heart failure (HF) and intracellular Na + BEAT-HF

Background –Acute hemodynamic effects of ß3 AR stimulation in heart failure BEAT-HF Bundgaard H et al. Circulation (25): In the normal heart a ß3 AR agonist has a negative inotropic effect because it reduces Na i and, via Na-Ca exchanger – reduces Ca i In HF - characterized by ”Na i overloaded myocytes” - a decrease in Na i with injection of a ß3 AR agonist should improve LV function LV function in normal sheep heart LV function in stable severe HF after coronary micro-embolization Do these results translate into improved LV function with chronic ß3 AR agonist treatment in human HF? IV injection of ß3 AR agonist in increasing doses

To investigate the effect of a ß3 AR agonist, Mirabegron on left ventricular ejection fraction in patients with chronic heart failure Single center, double-blind, placebo- controlled, randomized trial Randomization 1:1 to Mirabegron 300 mg daily, or placebo for 6 months Sample size: 70 patients - 90% power, - change left ventricular ejection fraction of 4% (the primary end-point) - two-sided p<0.05, - drop-out rate of 30%. Objective and study design BEAT-HF

Mirabegron; -FDA and EMA approved for overactive bladder (OAB) -Dose (25-)50 mg x 1 -T 1/2 =22-25 h, Cmax 3-4 h Side effects; – Increased BP and HR (off-target ß1/2 AR stimulation), – “Cold” symptoms, – Gastrointestinal discomfort Maximum reported dosage for OAB over12 weeks: 300 mg/day Doses administered in this study: – Start; 25 mg x 2 – then – if tolerated - weekly increases; – 50 mg x 2, 100 mg x 2, 150 mg x 2 (after a week 300 mg x1) BEAT-HF Study drug and dose

Primary endpoint -Change in left ventricular ejection fraction (LVEF) as assessed by CT Secondary outcomes (changes in) -NT-pro-BNP -Cardiac output/ stroke volume -Left ventricular volumes -Left atrial volume -Diastolic function -QT interval duration -Exercise tolerance -Symptoms BEAT-HF Endpoints

Key inclusion criteria – Stable heart failure on ischemic or non-ischemic basis – Left ventricular ejection fraction < 40% on screening echocardiography – On optimized evidence-based pharmacotherapy - stable > 4 weeks – The therapy must include a beta-blocker - to counterbalance ß1/2 effects Key exclusion criteria – Recent AMI or revascularization ( < 3 months) or CRT (< 6 months) – Significant obstructive valvular disease – Atrial fibrillation – Uncontrolled hypertension (sBT ≥180 mmHg, dBT ≥ 110 mmHg) – Renal (eGFR x3) diseases – Treatment with digoxin, tricyclic antidepressants or other CYP2D6 inhibitors than betablockers Eligibility BEAT-HF

Study design BEAT-HF Screened (n=142) 37 declined participation 33 Screen failure 12 ejection fraction ≥ 40% 5 Renal failure 5 Atrial fibrillation 4 BMI > 35 3 Drug contra-indications 6 Other Eligible (n=107) Randomized (n=70) Placebo (n=35) Mirabegron (n=35) 2 Deaths 1 Adverse effects 1Admitted - endocarditis 1 Admitted - urinary tract infection 1 Reduced compliance Follow-up data analyzed (n=29) 1 Adverse effects 2 Reduced compliance Follow-up data analyzed (n=32) Follow up 6 months

Baseline characteristics - 1 Placebo (n=35) Mirabegron (n=35) p Demographic characteristics Age – yr56±1262± Female sex – no. (%)4 (11) 1.0 Medical history Ischemic heart failure – no. (%) 16 (46)15 (43)0.91 Revascularised – no. (% of patiens with ischemic HF)12 (75)11 (73) Non-ischemic heart heart failure19 (54)20 (57)0.91 Previous cardiac arrest, sustained VT and/or a appropriate ICD shock – no. (%) 19 (54)20 (57)0.91 Diabetes – no. (%)3(9)5(14)0.71 Cardiac medications – no. (%) Beta-blocker35 (100) 1.0 ACE/ARB35 (100)33(94)0.49 Spironolactone/Eplerenone – no. (%) Other diuretics – no. (%) Symptoms and physical function 21 (60) 17 (49) 27 (77) 16 (46) New York Heart Association class II/III – no. (%)33 (94) / 2 (5)34(97) / 1 (3)0.51 VO 2 max (ml/kg/min)21±620±70.40 BEAT-HF

Baseline characteristics - 2 BEAT-HF Placebo (n=35) Mirabegron (n=35) P Vital signs Systolic blood pressure – mmHg124±19122± Diastolic blood pressure – mmHg 78±1275± Heart rate66±1062± Echocardiographic findings Left ventricular ejection fraction – %34±732± Volumetric and mass parameters by CT Left ventricular ejection fraction (%)38±1740± Left ventricular end diastolic volume (ml/m 2 ) 131±45129± Left ventricular end systolic volume (ml/m 2 ) 84±4280± Left stroke volume (ml/m 2 )47±1149± Left ventricular mass – g/m 2 81±1879± Left atrial volume – ml/m 2 62±2070±

All 61 patients completing the study were compliant by pill count (> 98%) 66 patients (94%) reached target dose of 300 mg daily, 3 patients 200 mg (Mirabegron), 1 patient 100 mg daily (Placebo). Compliance and safety BEAT-HF mmHg Beats pr min Mirabegron Placebo Baseline 6 months Mean difference 2.2 (95% CL, -5.2 to 9.5) P=0.55 Mean difference -0.3 (95% CL, -6.0 to 5.5) P=0.91 Systolic BPDiastolic BP Mean difference 0.6 (95% CL, -3.2 to 6.3) P=0.52 Heart rate mmHg

Primary endpoint BEAT-HF Left ventricular ejection fraction P= 0.82 Mean difference 0.4% (95% CL, -3.5 to 3.8) LVEF (%) Mirabegron Placebo Baseline6 months

Secondary endpoints BEAT-HF Placebo (n=32)Mirabegron (n=29) BaselineFollow-upChangeBaselineFollow-upChange Between group difference (95%CI) p Volumetric parameters by CT Left ventricular end diastolic volume ml 276±114269±116-7±33263±80257±78-6±271((-15)-16)0.95 Left ventricular end systolic volume ml 178±103175±107-4±30160±80152±68-8±27-4((-19)-11)0.56 Stroke volume ml97±2595±24-3±13102±26101±28-1±311((-11)-13)0.85 Left atrial volume ML131±48 125±47-5±15 143±31141±37-2±17 3±((-5) Physical capacity NYHA class I/II/III (%)0/8/9116/72/13-0/97/324/72/ min walking distance m487±101494±987±52493±83492±98-1±35-8((-32)-15)0.49 VO 2 max (ml/kg/min)21±6 -1±420±722±81±51±51((-4)-6)0.74 Laboratory measurements NT-pro-BNP - pmol/l87±10791±1294±7266±5577±7811±517((-25)-40)0.65 ECG QT interval ms430±52428±38-2±36446±35440±43-6±20-4((-20)-11)0.57

Exploratory analyses BEAT-HF Baseline6 months Baseline Baseline LVEF (CT) < 40%Baseline LVEF (CT) ≥ 40% P= 0.40 Mean difference -2.0% (95% CL, -6.8 to 2.8) P<0.03 Mean difference 5.5% (95% CL, ) Mirabegron Placebo

Adverse events BEAT-HF Placebo (n=35)Mirabegron (n=35)p Serious adverse events Sudden death 02 NS Appropriate ICD shock for VT/VF31NS Chest pain02NS Renal impairment10NS Fever/infection13NS Any adverse events Serious adverse events (no. of patients)58NS Other adverse event (no. of patients)812NS Discontinuation for adverse events Admitted with urinary tract infection01NS Admitted with device endocarditis01NS Hypersensitivity01NS Unspecific symptoms10NS

Mirabegron did not increase LVEF in patients with a mean EF of 40% There was no significant effects on the secondary endpoints The target dose was reached in 94% of the patients Safety profile – incl. blood pressure, heart rate, and │QT│ - seemed acceptable and adverse events were generally mild and transient The exploratory analysis indicated an increase in LVEF in patients with more severe HF at baseline, but not in patients with EF ≥ 40% Conclusions BEAT-HF

The beneficial effect of the β3 AR agonist only in severe heart failure is in agreement with the mechanistic foundation of our study An additional study on effects of β3 AR agonists in patients with severe heart failure is needed for the design of a phase III trial Implications BEAT-HF

The Research Fund of Rigshospitalet The Heart Center Research Foundation The Novo Nordic Foundation The A.P. Møller and Chastine Mc-Kinney Møller Foundation Funding INHERIT